A Country Doctor Reads: July 28, 2019

Where Have All The Young Docs Gone? – NEJM

The New England Journal of Medicine published a sobering piece about the rapid changes in age distribution among rural physicians. They also point out that the aging and chronic disease burden of the US rural population is expected to increase demand for rural medical providers.

“Maintaining physician supply in rural areas has important equity implications, given that, as compared with more urban populations, rural residents are likely to be older and poorer, are more commonly uninsured, and have lower life expectancy.”

The article by Skinner et al makes a few suggestions about what to do to forestall what they describe as an evolving crisis, from loan repayment to hiring more Nurse Practitioners.

I think these types of strategies are unlikely to reverse what is a bigger trend in our society. As a 66 year old physician moving back to Caribou, Maine, I see the challenges of my community all around me: A more than half empty shopping mall in Presque Isle, the closing of a 100 employee customer service call center in Caribou, the empty store fronts lining Main Street in Van Buren. It isn’t just the physician work force that is changing, de demographics of rural America are changing.

It’s strange in a way, when our world is increasingly well connected and distances appear to mean less and less (if only my Internet connection were better and less expensive…) why being physically located in an urban area is so attractive.

In rural New England people don’t need to lock their cars or their houses, they don’t have to stand in line, sit in traffic or feel crowded by the noise around them. But they do need jobs that pay a decent wage. That’s the problem here. Fix the economy (if you can) and the health disparities will diminish.

As the number of younger physicians entering rural practice has declined, the rural physician workforce has grayed. By 2017, more than half of rural physicians were at least 50 years old, and more than a quarter were at least 60. In contrast, the number of urban physicians under 50 grew 12% from 2000 to 2017, and in 2017 only 39% of urban physicians were 50 years of age or older and only 18% were at least 60.
— Read on www.nejm.org/doi/full/10.1056/NEJMp1900808

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Switch

Moving into my new home office I constantly run into books I bought and read years ago but have thought little of since. One book I haven’t read since I first bought it but often keep referring to is “Switch” by Chip and Dan Heath. Subtitled “How to change things when change is hard”, the book has given me a lot to think about as a doctor, whose job often involves trying to cause my patients to change for the purpose of achieving better health.

The three steps to consider when asking someone, even yourself, to change are described, metaphorically as:

1.) Direct the rider. This is what we doctors usually try to do when we tell our patients to eat less, exercise more or take their pills every day.

2.) Motivate the elephant. This is harder, because it involves addressing the subconscious, which cares very little about things like logic or what’s best for us.

3.) Shape the path. If we make it easier somehow to do the “right” thing than the “wrong” thing, people are more likely to do it.

The book has illustrations from all walks of life, from health care to teaching to sales. And, after all, practicing medicine is part teaching and part sales, too.

The central idea for me is how necessary it is to understand and communicate with the elephant, the Heath brothers metaphor for our subconscious. I guess moving our subconscious is not only like riding an elephant, but also a lot like moving horses into a new environment.

I can’t just tell these guys what I would like them to do, I have to find ways to motivate them that are natural for them, that they might want to do in some fashion anyway.

The notion of shaping the path is something I also keep coming back to. So many times we hear that people just aren’t doing what they’re supposed to do, when in fact we are being asked to do things that seem awkward, silly or even impossible.

The recent Boeing crashes due to a software redesign that may have looked good on paper but didn’t make any sense to airline pilots comes to mind.

Similarly, in my world, the “work flows” of modern EMRs may look all right to a computer programmer, but make little sense to health care personnel.

So often in our culture, people are blamed for things that are systems problems and not people problems at all.